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Assessing quality of care in Malawi’s Support for Service Delivery and Integration Project’s Performance Based Incentives Intervention

A woman participates in a voluntary testing for HIV campaign in Chiradzulu, Malawi. © 2007 Bonex Julius, Courtesy of Photoshare


In Malawi, primary healthcare provision is largely based on an essential healthcare package (EHP), the set of health services that are meant to be provided free of charge in both public and private, not-for-profit facilities. Essential health services are not as widely available or as widely utilized as needed to achieve the Government of Malawi’s health objectives.

Addressing the Challenge

The Ministry of Health is piloting a performance based incentives (PBI) program with support from USAID Malawi’s flagship health project, Support for Service Delivery Integration (SSDI), in order to improve the availability and uptake of services. The PBI pilot program is currently underway in three target districts.  The SSDI-PBI program aims to increase access, utilization, and quality indicators across a range of health areas including maternal and child health. The SSDI-PBI pilot project is unique from other PBI projects, both in Malawi and globally, in that financial incentives are awarded exclusively to facilities upon achievement of set targets, and not to individual health workers. 

Project Location

The study takes place in four districts in Malawi: Chitipa, Nkhotakota, and Mangochi.

Research Objectives

Research questions include:
  1. To what extent has the PBI intervention been implemented according to the original implementation plan?
    • What contextual factors have affected implementation, acceptance and adoption?
    • What differences in effects can be concerned across districts and facilities, and what factors explain those differences?
  2. To what extent have the verification and counter-verification processes worked as planned?
    • To what extent has the SSDI-PBI intervention produced changes in the quantity and quality of services provided?
  3. To what extent have changes affected incentivized vs. non-incentivized services?
    • Has the SSDI-PBI intervention changed providers’ motivation? Are changes in motivation reflected in changes in behavior at work?
  4. How does the cost of implementing the SSDI-PBI intervention relate to produced outcomes? How do investments related to incentives being paid?

Study Approach

This study examines the implementation of the SSDI-PBI program to determine whether it resulted in changes in quantity and quality of medical services provided and in provider motivation, and to assess the costs of the intervention in relation to the outputs. The study will use a mixed methods approach. 
To assess fidelity to the implementation plan, quantitative data will be collected through structured interviews with key intervention personnel as well as a structured document review. In-depth interviews (IDIs) and focus group discussions (FGDs) among implementers and providers will help to explain the implementation process and the acceptability and adoption of the intervention. 
Researchers will extract facility and service assessment data from existing sources of program data to examine changes in service quantity and quality at the facility level. In addition, IDIs with clients and FDGs with community members will gather data on client perceptions of the service quality.
To examine provider motivation and behavior, a structured survey and IDIs will collect data on provider motivation and perceptions of the changes in their own behavior that took place during implementation as a result of the PBI intervention.
Finally, a cost-consequence analysis (CCA) will be used for comparison of costs and benefits that are measured in different units. Cost data will be collected through a financial document review and linked with quantity and quality outputs that will be measured as a part of the second research objective. 

Research into Action

Results from this study will be used by the Malawi Ministry of Health and USAID in planning the future role of PBI within quality improvement efforts. This study may also provide valuable insights for policy makers and implementers beyond Malawi as it focuses on a non-typical PBI intervention design and is therefore a unique contribution in the field. 


University of Heidelberg Institute of Public Health (IPHHD)
University of Malawi College of Medicine (COM)
Bocconi University Center for Research on Health and Social Care Management (CERGAS)




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